Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting

Abstract

ImportanceEarly pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ.ObjectiveTo compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics.Design, Setting, and ParticipantsThis retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022.ExposuresThe primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities.Main Outcomes and MeasuresThe primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis.ResultsA total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service.Conclusions and RelevanceIn this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

Variations in Care for Early Pregnancy Loss Across Clinical Settings

“…First, most patients (96 923 patients [82.3%]) received their initial care for EPL in the outpatient clinic, as opposed to the ED. 3 An important, but perhaps unsurprising, finding is that the patients who presented to an ED first were different in their demographic and clinical characteristics than those who presented first to an outpatient clinic. The ED patients were younger (mean [SD] age, 29.6 [6.7] vs 32.2 [5.9] years) and were markedly more likely to be a dependent on the insurance plan as opposed to the primary insurance holder (4994 patients [22.1%] vs 8303 patients [8.6%]).…”

“…The ED patients were younger (mean [SD] age, 29.6 [6.7] vs 32.2 [5.9] years) and were markedly more likely to be a dependent on the insurance plan as opposed to the primary insurance holder (4994 patients [22.1%] vs 8303 patients [8.6%]). 3 They were also less likely to have established prenatal care. Given their age and lower odds of having established outpatient care, the patients who presented to the ED first may also be more at risk for disparities in care.…”

“…Although we do not know their race, ethnicity, or income from these data, 3 racial disparities are an important consideration in EPL care, because both incidence and sequalae differ by race in the US. 4 Another important finding from the study by Benson et al 3 is that patients who presented first to an ED received different EPL care than those who presented to an outpatient setting. Although this study cannot determine the treatment preferences of the patients, it can and does tell us about important differences between patients who received care in one setting vs the other.…”

“…The most drastic differences between the ED and outpatient cohorts were seen in the medication management approaches, where only 1116 patients (5.4%) in the ED received medications for EPL compared with 10 878 patients (11.2%) in the outpatient cohort. 3 It is important to note that because this is an observational study, 3 there are almost certainly unmeasured confounders and effect modifiers that limit the ability to infer the extent to which the differences in care between the ED and clinic cohort of patients are associated with the patients' initial decisions to seek care for their EPL symptoms in an ED or clinic setting. We note that the investigators found that the patients who first presented to the ED were more likely than patients who presented to an outpatient clinic to receive a blood transfusion, 3 which is most likely because patients in the ED nearly always have higher acuity presentations than those who present to an outpatient clinic, even after adjusting for comorbidities.…”

“…3 It is important to note that because this is an observational study, 3 there are almost certainly unmeasured confounders and effect modifiers that limit the ability to infer the extent to which the differences in care between the ED and clinic cohort of patients are associated with the patients' initial decisions to seek care for their EPL symptoms in an ED or clinic setting. We note that the investigators found that the patients who first presented to the ED were more likely than patients who presented to an outpatient clinic to receive a blood transfusion, 3 which is most likely because patients in the ED nearly always have higher acuity presentations than those who present to an outpatient clinic, even after adjusting for comorbidities. Statistical approaches for observational studies that can be used to mimic experimental designs and make tighter causal inferences were not used here because of limitations of the claims data set.…”